Riesgo de accidente cerebrovascular en pacientes con aterosclerosis carotídea asintomática: ¿se debe tratar médicamente o quirúrgicamente?

Autores/as

DOI:

https://doi.org/10.24265/horizmed.2023.v23n3.11

Palabras clave:

Accidente Cerebrovascular, Riesgo, Enfermedades de las Arterias Carótidas , Procedimientos Quirúrgicos Operativos, Terapéutica

Resumen

Los desórdenes cerebrovasculares siguen siendo la primera causa de morbilidad y mortalidad neurológica en el mundo, representando una de las entidades patológicas que genera mayor carga de enfermedad a nivel global. La aterosclerosis,
o estenosis carotídea, es un potencial factor de riesgo para el ictus isquémico. La identificación y seguimiento estricto de esta condición son esenciales en la prevención secundaria de complicaciones a través de la atención primaria y
el manejo especializado del riesgo cardiometabólico. No obstante, dependiendo de este riesgo y/o la presencia de sintomatología, es necesario realizar un manejo definitivo. Actualmente, existe controversia sobre si es mejor tratar la estenosis carotídea asintomática, ya sea médica o quirúrgicamente. Teniendo en cuenta la relevancia de esta entidad, el
objetivo de esta revisión consiste en analizar la evidencia reciente sobre el riesgo de ictus isquémico en la aterosclerosis carotídea asintomática en adultos, y el potencial beneficio del manejo quirúrgico vs. farmacológico de esta condición.
Para esto, se llevó a cabo una búsqueda bibliográfica en las bases de datos PubMed, ScienceDirect, Web of Science y MEDLINE, hasta el año 2023. Se evidenció que el riesgo de ictus asociado a estenosis carotídea asintomática es significativo (>10 %, aproximadamente), incluso en aquellos con terapia antiplaquetaria e hipolipemiante activa. En aquellos con manejo médico, la supervivencia a cinco años es alrededor del 80 %. Sin embargo, la progresión de la estenosis sucede en promedio en más del 60 % de los casos, y es significativa. Por el contrario, el stent carotídeo y la endarterectomía son intervenciones resolutivas. Pero existe un riesgo mayor comparado con la terapia médica, el cual se atribuye al periodo
peri- y posoperatorio, así como a 30 días de aparición o recurrencia del ictus, infarto agudo de miocardio o muerte por cualquier causa; aunque el uso de la endarterectomía ha demostrado beneficios superiores a largo plazo en cuanto a estos mismos desenlaces. Entonces, la evidencia es heterogénea en cuanto a la superioridad del tratamiento quirúrgico
comparado con la terapia farmacológica en el manejo de la aterosclerosis o estenosis carotídea asintomática. Sin embargo, parece ser que el manejo quirúrgico, específicamente la endarterectomía, podría impactar significativamente sobre la aparición o recurrencia del ictus ipsilateral y muerte a largo plazo, pero con resultados controversiales peri- y
postoperatorios.

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Parish S, Arnold M, Clarke R, Du H, Wan E, Kurmi O, et al. Assessment

of the role of carotid atherosclerosis in the association between

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JAMA Netw Open [Internet]. 2019;2(5):e194873.

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and regional prevalence, burden, and risk factors for carotid 1. GBD 2019 Stroke Collaborators. Global, regional, and national burden

of stroke and its risk factors, 1990-2019: a systematic analysis for

the Global Burden of Disease Study 2019. Lancet Neurol [Internet].

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Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and countryspecific burden of ischaemic stroke, intracerebral haemorrhage

and subarachnoid haemorrhage: A systematic analysis of the Global

Burden of Disease Study 2017. Neuroepidemiology [Internet].

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Zhang T, Yin X, Zhang Y, Chen H, Man J, Li Y, et al. Global trends in

mortality and burden of stroke attributable to lead exposure from

to 2019. Front Cardiovasc Med [Internet]. 2022;9:870747.

Portegies ML, Koudstaal PJ, Ikram MA. Cerebrovascular disease.

Handb Clin Neurol [Internet]. 2016;138:239-61.

Pan American Health Organization. Cardiovascular disease burden

[Internet]. Disponible en: https://www.paho.org/en/enlace/

cardiovascular-disease-burden

World Health Organization. Cerebrovascular disease [Internet].

Disponible en: https://platform.who.int/mortality/themes/themedetails/topics/indicator-groups/indicator-group-details/MDB/

cerebrovascular-disease

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al. The burden of cerebrovascular disease in the United States. Prev

Chronic Dis [Internet]. 2019;16(180411):E52.

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associations between visceral adiposity index and cardiovascular

and cerebrovascular diseases: Results from the NHANES (1999-2018).

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diseases in the UK [Internet]. University of Oxford; 2009. Disponible

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studies-28/the-economic-burden-of-cerebrovascular-diseases-inthe-uk-2

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2023-09-13

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Moreno Muñoz RN, Vergara Trujillo RA, Guevara Lizarazo GA, Brett Cano PJ, León Cuervo DA, Puerta Lidueñas AM, Sarmiento Figueroa M, Ortega Sierra M. Riesgo de accidente cerebrovascular en pacientes con aterosclerosis carotídea asintomática: ¿se debe tratar médicamente o quirúrgicamente?. Horiz Med [Internet]. 13 de septiembre de 2023 [citado 22 de febrero de 2024];23(3):e2245. Disponible en: https://www.horizontemedico.usmp.edu.pe/index.php/horizontemed/article/view/2245

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